• Giulia Catozzi, Tommaso Pozzi, Domenico Nocera, Beatrice Donati, Stefano Giovanazzi, Valentina Ghidoni, Mauro Galizia, Rosanna D'Albo, Mattia Busana, Federica Romitti, Alessandro Gatta, Onnen Moerer, Konrad Meissner, Michael Quintel, Peter Herrmann, Davide Chiumello, Luigi Camporota, and Luciano Gattinoni.
• Department of Anaesthesiology, University Medical Center Göttingen, Göttingen, Germany.
• Intensive Care Med. 2024 Dec 11.

PurposeThe selection and intensity of respiratory support for ARDS are guided by PaO2/FiO2. However, ventilator-induced lung injury (VILI) is linked to respiratory mechanics and ventilator settings. We explored whether the VILI risk is related to ARDS severity based on oxygenation.MethodsWe analysed data on 228 ARDS subjects with PaO2/FiO2 < 200 mmHg, categorized into three severity groups: one based on PaO2/FiO2 ratio, and the others based on tertiles of predictors of VILI: mechanical power ratio (MPR) and driving pressure (DP). In each group of oxygenation-based ARDS severity and MPR and DP tertiles, we measured CT anatomy, gas exchange, respiratory mechanics, VILI prerequisites (lung elastance and lung gas volume), and VILI determinants (tidal volume, PEEP, airway pressures).ResultsPredictors of VILI, such as MPR and DP, were similar across ARDS severity groups based on PaO2/FiO2 ratio, while oxygenation remained comparable across different levels of VILI risk defined by MPR and DP. Oxygenation impairment was associated with increased lung weight, recruitability, and reduced well-inflated tissue. In contrast, MPR and DP tertiles affected variables associated with the baby lung size, such as lung gas volume and well-inflated tissue. Mechanical ventilation intensity increased progressively across MPR and DP tertiles, but remained similar across PaO2/FiO2 severity groups.ConclusionsARDS severity based on oxygenation impairment does not reflect the prerequisites and determinants of VILI. This should prompt a reconsideration of recommending respiratory support based on oxygenation impairment, rather than VILI determinants.© 2024. The Author(s).

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